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Pizzo E, Avşar TS, Abraldes JG, Genesca J, Tsochatzis EA. Cost-Effectiveness of the Baveno VI Criteria Compared With Endoscopy for High-Risk Varices in Patients With Child-Pugh A Cirrhosis. Clin Gastroenterol Hepatol 2024; 22:2053-2061. [PMID: 38777174 DOI: 10.1016/j.cgh.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND & AIMS Although upper gastrointestinal endoscopy (EGD) remains the gold standard for detecting varices in cirrhosis, the Baveno VI criteria proposed a combination of transient elastography and platelet count that could rule out high-risk varices, therefore sparing the need for an endoscopy, with significant potential cost savings. We performed a cost-effectiveness analysis of the Baveno VI criteria compared with EGD in the diagnosis of high-risk varices in cirrhosis. METHODS We built an analytical decision model to estimate the cost and benefits of using the Baveno VI criteria compared with EGD in patients with Child-Pugh A cirrhosis. The analysis was performed from the UK National Health Service perspective, over 1, 5, and 20 years. A Markov model was populated with data from published evidence. Outcomes were measured in terms of quality-adjusted life years (QALYs) and avoided deaths. The analyses were repeated for Canada and Spain, using relevant cost inputs. RESULTS The Baveno VI criteria were cost effective compared with endoscopy in all analyses. For 1000 patients, they produced 0.16 additional QALYs at an incremental cost of £326 ($443.41) over 5 years, resulting in an incremental cost of £2081 ($2830) per additional QALY gained. The incremental net monetary benefit of Baveno VI compared with EGD was £2808 ($3819) over 5 years per patient. Baveno VI criteria also were cost effective in Canada and Spain. Deterministic and probabilistic sensitivity analysis supported these findings. CONCLUSIONS The findings demonstrate that the Baveno VI criteria are cost effective, suggesting that they should be considered for widespread implementation on the basis of safety, appropriateness, and economic grounds.
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Affiliation(s)
- Elena Pizzo
- Department of Applied Health Research, University College London, London, United Kingdom.
| | - Tuba Saygın Avşar
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Juan G Abraldes
- Division of Gastroenterology, Liver Unit, University of Alberta, Edmonton, Canada
| | - Joan Genesca
- Liver Unit, Digestive Diseases Division, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Emmanuel A Tsochatzis
- University College London Institute for Liver and Digestive Health, Royal Free Hospital and University College London, London, United Kingdom.
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Brata VD, Incze V, Ismaiel A, Turtoi DC, Grad S, Popovici R, Duse TA, Surdea-Blaga T, Padureanu AM, David L, Dita MO, Baldea CA, Popa SL. Applications of Artificial Intelligence-Based Systems in the Management of Esophageal Varices. J Pers Med 2024; 14:1012. [PMID: 39338266 PMCID: PMC11433421 DOI: 10.3390/jpm14091012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Revised: 09/04/2024] [Accepted: 09/21/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Esophageal varices, dilated submucosal veins in the lower esophagus, are commonly associated with portal hypertension, particularly due to liver cirrhosis. The high morbidity and mortality linked to variceal hemorrhage underscore the need for accurate diagnosis and effective management. The traditional method of assessing esophageal varices is esophagogastroduodenoscopy (EGD), which, despite its diagnostic and therapeutic capabilities, presents limitations such as interobserver variability and invasiveness. This review aims to explore the role of artificial intelligence (AI) in enhancing the management of esophageal varices, focusing on its applications in diagnosis, risk stratification, and treatment optimization. METHODS This systematic review focuses on the capabilities of AI algorithms to analyze clinical scores, laboratory data, endoscopic images, and imaging modalities like CT scans. RESULTS AI-based systems, particularly machine learning (ML) and deep learning (DL) algorithms, have demonstrated the ability to improve risk stratification and diagnosis of esophageal varices, analyzing vast amounts of data, identifying patterns, and providing individualized recommendations. However, despite these advancements, clinical scores based on laboratory data still show low specificity for esophageal varices, often requiring confirmatory endoscopic or imaging studies. CONCLUSIONS AI integration in managing esophageal varices offers significant potential for advancing diagnosis, risk assessment, and treatment strategies. While promising, AI systems should complement rather than replace traditional methods, ensuring comprehensive patient evaluation. Further research is needed to refine these technologies and validate their efficacy in clinical practice.
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Affiliation(s)
- Vlad Dumitru Brata
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Victor Incze
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Abdulrahman Ismaiel
- 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (A.I.); (S.G.); (T.S.-B.); (L.D.); (S.L.P.)
| | - Daria Claudia Turtoi
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Simona Grad
- 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (A.I.); (S.G.); (T.S.-B.); (L.D.); (S.L.P.)
| | - Raluca Popovici
- Faculty of Environmental Protection, University of Oradea, 26 Gen. Magheru St., 410087 Oradea, Romania;
| | - Traian Adrian Duse
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Teodora Surdea-Blaga
- 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (A.I.); (S.G.); (T.S.-B.); (L.D.); (S.L.P.)
| | - Alexandru Marius Padureanu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Liliana David
- 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (A.I.); (S.G.); (T.S.-B.); (L.D.); (S.L.P.)
| | - Miruna Oana Dita
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (V.D.B.); (D.C.T.); (T.A.D.); (A.M.P.); (M.O.D.)
| | - Corina Alexandrina Baldea
- Faculty of Environmental Protection, University of Oradea, 26 Gen. Magheru St., 410087 Oradea, Romania;
| | - Stefan Lucian Popa
- 2nd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (A.I.); (S.G.); (T.S.-B.); (L.D.); (S.L.P.)
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Dajti E, Villanueva C, Berzigotti A, Brujats A, Albillos A, Genescà J, Garcia-Pagán JC, Colecchia A, Bosch J. Exploring algorithms to select candidates for non-selective beta-blockers in cirrhosis: a post-hoc analysis of the PREDESCI trial. J Hepatol 2024:S0168-8278(24)02553-4. [PMID: 39303875 DOI: 10.1016/j.jhep.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 09/03/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND & AIMS Whether non-invasive tests (NITs) can accurately select patients with cirrhosis requiring non-selective beta-blockers (NSBB) for clinically significant portal hypertension (CSPH) and prevention of decompensation is unclear. Our aim was to test the performance of NIT-based algorithms for CSPH diagnosis using the prospective PREDESCI cohort. We investigated a new algorithm combining NITs with endoscopy to improve performance. METHODS We included patients with compensated cirrhosis and available liver elastography who were screened during the trial. The performance of models based on liver stiffness measurement (LSM) and platelet count was evaluated. An algorithm considering endoscopy for patients with inconclusive results (the "grey zone") was then developed and validated in an independent cohort of 195 patients in whom also spleen stiffness was available. RESULTS We included 170 patients from the PREDESCI cohort. An LSM≥25 kPa alone (Baveno VII criteria) or an LSM>20 kPa plus thrombocytopenia (AASLD criteria) ruled-in CSPH with positive predictive value of 88 and 89%, respectively. However, 37%-47% patients fell into the grey zone while at high-risk of decompensation or death. Performing endoscopy in inconclusive cases identified patients with varices that, when re-classified as high-risk for CSPH, significantly reduced the grey zone to 22%. In this algorithm, 86% of CSPH patients were correctly classified as high-risk. The diagnostic performance was confirmed in the external validation cohort, where combining Baveno VII criteria with spleen stiffness showed similar accuracy to the model using endoscopy. CONCLUSIONS Algorithms based only on LSM and platelet count are suboptimal to identify NSBB treatment candidates. Performing endoscopy in patients with indeterminate findings from NITs improved diagnostic performance and risk stratification. Endoscopy may be substituted by spleen stiffness for stratifying the risk in the grey zone. IMPACT AND IMPLICATIONS The PREDESCI trial demonstrated that non-selective beta-blockers prevent decompensation in CSPH patients. Still it is unclear whether we can select treatment candidates using non-invasive tests to assess the presence of CSPH without measuring HVPG. In the prospective cohort of patients screened during the trial, we showed that algorithms based on liver stiffness and platelet count had suboptimal performance, mainly due to a high rate of indeterminate results. Performing endoscopy in the grey zone patients allowed to significantly increase the number of patients with CSPH and improved the risk stratification for decompensation or death on long-term follow-up. These findings were validated in an independent cohort. In addition, a model using spleen stiffness instead of endoscopy showed similar diagnostic performance in the external validation cohort, suggesting that adequate risk stratification to select treatment candidates can be achieved with a fully non-invasive algorithm.
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Affiliation(s)
- Elton Dajti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna; European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Bologna, Italy
| | - Càndid Villanueva
- Department of Digestive Diseases. Hospital de la Santa Creu i Sant Pau. Biomedical Research Institute Sant Pau (IIB Sant Pau). Barcelona. Medicine Department, Autonomous University of Barcelona; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Anna Brujats
- Department of Digestive Diseases. Hospital de la Santa Creu i Sant Pau. Biomedical Research Institute Sant Pau (IIB Sant Pau). Barcelona. Medicine Department, Autonomous University of Barcelona
| | - Agustín Albillos
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Department of Gastroenterology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Joan Genescà
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Liver Unit, Digestive Diseases Division, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan C Garcia-Pagán
- Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Department de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain
| | - Antonio Colecchia
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Jaume Bosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, Bern, Switzerland; Centre for Biomedical Research in Liver and Digestive Diseases Network (CIBERehd), Madrid, Spain; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE-Liver). Department de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain.
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Bañares J, Aceituno L, Pons M, Genescà J. Noninvasive Assessment of Portal Hypertension. Clin Liver Dis 2024; 28:401-415. [PMID: 38945634 DOI: 10.1016/j.cld.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
The progressive use of noninvasive tests (NITs) has changed the way hepatologists diagnose and manage patients with chronic liver disease, mainly because of their easiness to use and the ability to be repeated during follow-up. Liver stiffness measurement is the NIT with more scientific evidence. NITs have demonstrated to be useful to detect not only liver fibrosis but also the presence of clinically significant portal hypertension. Moreover, current evidence supports they can also be useful to evaluate the prognosis of patients with chronic liver disease.
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Affiliation(s)
- Juan Bañares
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Laia Aceituno
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain
| | - Mònica Pons
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Joan Genescà
- Liver Unit, Digestive Diseases Area, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Pg. Vall d'Hebron 119-129, Barcelona 08035, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
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Vanderschueren E, Armandi A, Kwanten W, Cassiman D, Francque S, Schattenberg JM, Laleman W. Spleen Stiffness-Based Algorithms Are Superior to Baveno VI Criteria to Rule Out Varices Needing Treatment in Patients With Advanced Chronic Liver Disease. Am J Gastroenterol 2024; 119:1515-1524. [PMID: 38502095 DOI: 10.14309/ajg.0000000000002708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION The Baveno VI criteria have set the stage for noninvasive assessment of compensated advanced chronic liver disease (ACLD). The algorithm combining liver stiffness measurement (LSM, <20 kPa) and platelet count (>150,000/μL) safely avoids screening endoscopy for varices needing treatment (VNT) but identifies only a relatively low number of patients. We aimed to evaluate the value of spleen stiffness measurement (SSM) using spleen-dedicated elastography in ruling out VNT. METHODS In this real-life multicenter retrospective derivation-validation cohort, all consecutive patients with ACLD (defined by LSM ≥10 kPa) with available upper endoscopy, laboratory results, spleen diameter, LSM, and SSM measured with spleen-dedicated transient elastography were included. VNT were defined as medium-to-large varices or small varices with red spots. RESULTS In the derivation cohort (n = 201, 11.9% VNT), SSM demonstrated excellent capability at identifying VNT (area under the receiver operating characteristic curve [AUROC] 0.88), outperforming LSM (AUROC 0.77, P = 0.03) and platelets (AUROC 0.73, P = 0.002). In comparison with Baveno VI criteria (33.8% spared endoscopies), the sequential Baveno VI plus SSM and a novel spleen size and stiffness model were able to increase the number of patients avoiding endoscopy (66.2% and 71.1%, respectively) without missing more than 5% of VNT. These findings were confirmed in an external validation cohort of patients with more advanced liver disease (n = 176, 34.7% VNT) in which the number of spared endoscopies tripled (27.3% and 31.3% for SSM-based algorithms) compared with Baveno VI criteria (8.5%). DISCUSSION Spleen stiffness-based algorithms are superior to Baveno VI criteria in ruling out VNT in patients with ACLD and double the number of patients avoiding screening endoscopy.
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Affiliation(s)
- Emma Vanderschueren
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Angelo Armandi
- Metabolic Liver Disease Research Program, I Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Division of Gastroenterology and Hepatology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Wilhelmus Kwanten
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - David Cassiman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
| | - Sven Francque
- Laboratory of Experimental Medicine and Paediatrics (LEMP), University of Antwerp (UA), Antwerp, Belgium
- Department of Gastroenterology & Hepatology, University Hospital Antwerp, Antwerp, Belgium
| | - Jörn M Schattenberg
- Department of Internal Medicine, Saarland University Medical Center, Homburg, Germany
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Catholic University of Leuven, Leuven, Belgium
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Laleman W, Peiffer KH, Tischendorf M, Ullerich HJ, Praktiknjo M, Trebicka J. Role of endoscopy in hepatology. Dig Liver Dis 2024; 56:1185-1195. [PMID: 38151452 DOI: 10.1016/j.dld.2023.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/29/2023]
Abstract
The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University Hospitals Leuven, KU Leuven, Leuven, Belgium; Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany.
| | - Kai-Henrik Peiffer
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Hans-Joerg Ullerich
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Michael Praktiknjo
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Medicine B (Gastroenterology, Hepatology, Endocrinology, Clinical Infectiology), University Hospital Muenster, Muenster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Laleman W, Vanderschueren E, Mehdi ZS, Wiest R, Cardenas A, Trebicka J. Endoscopic procedures in hepatology: Current trends and new developments. J Hepatol 2024; 80:124-139. [PMID: 37730125 DOI: 10.1016/j.jhep.2023.08.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023]
Abstract
Gastrointestinal endoscopy has long been a reliable backbone in the diagnosis and management of hepatobilary disorders and their complications. However, with evolving non-invasive testing, personalised medicine has reframed the utility and necessity of endoscopic screening. Conversely, the growing interest and use of endoscopic ultrasound (EUS) and advanced endoscopy within gastrointestinal units has also opened novel diagnostic and therapeutic avenues for patients with various hepatobiliary diseases. The integration of "advanced endoscopy" within the practice of hepatology is nowadays referred to as "endo-hepatology". In essence, endo-hepatology consists of two pillars: one focusing primarily on disorders of the liver parenchyma, vascular disorders, and portal hypertension, which is mainly captured via EUS, while the other targets the hepatobiliary tract via endoscopic retrograde cholangiopancreatography and advanced imaging. Applications under the umbrella of endo-hepatology include, amongst others, EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, coil and glue embolisation of gastric varices as well as cholangioscopy. As such endo-hepatology could become an attractive concept wherein advanced endoscopy might reinforce the medical management of patients with hepatobiliary disorders and their complications after initial basic work-up. In this review, we discuss current trends and future developments within endo-hepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium; Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany.
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Zain Seyad Mehdi
- Department of Mechanical Engineering, KU LEUVEN, Leuven, Belgium
| | - Reiner Wiest
- Department of Visceral Surgery and Medicine, University Inselspital, Bern, Switzerland
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain; Institute of Digestive Disease and Metabolism, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany; European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Laleman W, Mertens J, Vanderschueren E, Praktiknjo M, Trebicka J. Advances in Endohepatology. Am J Gastroenterol 2023; 118:1756-1767. [PMID: 37610016 DOI: 10.14309/ajg.0000000000002482] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/18/2023] [Indexed: 08/24/2023]
Abstract
Over the past decade, the number of endoscopic procedures relevant to patients with liver disease not only increased but also altered and expanded in terms of indications and applications. "Endohepatology" refers to the integration of advanced endoscopy within the practice of hepatology with endoscopic ultrasound as one of the main pillars. Current applications under the umbrella of endohepatology focus on advanced diagnostics and oncological, vascular, and metabolic interventions. These involve, among others, endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided coil and glue embolization of gastric varices. In addition to its conceptually attractive technical and innovative characteristics, endohepatology is also an appealing practical option for daily practice because it can be offered as a "one-stop clinic" intervention where comprehensive endoscopic diagnostic and/or therapeutic testing is performed in a single outpatient visit. In this review, we will discuss current trends and future developments within endohepatology and the remaining hurdles to overcome.
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Affiliation(s)
- Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Joachim Mertens
- Department of Gastroenterology & Hepatology, Klinik Hirslanden, Zurich, Switzerland
| | - Emma Vanderschueren
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic Disorders, University Hospitals Leuven, KU LEUVEN, Leuven, Belgium
| | - Michael Praktiknjo
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
| | - Jonel Trebicka
- Medizinische Klinik B, Universitätsklinikum Münster, Münster University, Münster, Germany
- European Foundation of Chronic Liver Failure, EFCLIF, Barcelona, Spain
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Segna D, Mendoza YP, Lange NF, Rodrigues SG, Berzigotti A. Non-invasive tools for compensated advanced chronic liver disease and portal hypertension after Baveno VII - an update. Dig Liver Dis 2023; 55:326-335. [PMID: 36369196 DOI: 10.1016/j.dld.2022.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022]
Abstract
Non-invasive tests (NITs) and liver stiffness measurement (LSM) in particular, have entered clinical practice over 20 years ago as point-of-care tests to diagnose liver fibrosis in patients with compensated chronic liver disease. Since then, NITs use has evolved thanks to a large number of studies in all major etiologies of liver disease, and they have become important tools to stratify the risk of portal hypertension and liver-related events. The Baveno VII consensus workshop provided several novel recommendations regarding the use of well-established and novel NITs in the specific setting of portal hypertension screening, diagnosis and follow-up. The Baveno VII expert panels paid special attention to summarizing the existing data into simple clinical rules able to guide clinicians in their practice. The "rule of five" for LSM is a tool to stratify the risk of liver-related events, and LSM alone or in combination with platelet count, can be used now to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and clinically significant portal hypertension, as well as to rule-out high-risk varices. Use of NITs in obese subjects with non-alcoholic fatty liver disease (NAFLD) and patients with viral hepatitis C that has been successfully treated, require specific knowledge. This review will update the reader on these aspects.
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Affiliation(s)
- Daniel Segna
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Yuly P Mendoza
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Naomi F Lange
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland; Graduate School for Health Sciences (GHS), University of Bern, Switzerland
| | - Susana G Rodrigues
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland
| | - Annalisa Berzigotti
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, BHH D115, Bern 3010, Switzerland.
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10
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Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, Jovanovic I, Awadie H, Hernandez-Gea V, Tantau M, Ebigbo A, Ibrahim M, Vlachogiannakos J, Burgmans MC, Rosasco R, Triantafyllou K. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:1094-1120. [PMID: 36174643 DOI: 10.1055/a-1939-4887] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
1: ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2-4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3-6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3: ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70-90 g/L is desired.Strong recommendation, moderate quality evidence. 4 : ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 : ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 : ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 : ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30-120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 : ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 : ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 : ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child-Pugh C ≤ 13 or Child-Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 : ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 : ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13: ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14: ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15: ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16: ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.
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Affiliation(s)
- Ian M Gralnek
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine Technion Israel Institute of Technology, Haifa, Israel
| | - Marine Camus Duboc
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA) & Assistance Publique-Hôpitaux de Paris (AP-HP), Endoscopic Center, Saint Antoine Hospital, Paris, France
| | - Juan Carlos Garcia-Pagan
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, IRCSS-S. Orsola-Malpighi, Hospital, Bologna, Italy
| | - John Gásdal Karstensen
- Gastroenterology Unit, Copenhagen University Hospital - Amager and Hvidovre, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tomas Hucl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Ivan Jovanovic
- Euromedik Health Care System, Visegradska General Hospital, Belgrade, Serbia
| | - Halim Awadie
- Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Hospital Clinic, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.,Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Marcel Tantau
- University of Medicine and Pharmacy 'Iuliu Hatieganu' Cluj-Napoca, Romania
| | - Alanna Ebigbo
- Department of Gastroenterology, Universitätsklinikum Augsburg, Augsburg, Germany
| | | | - Jiannis Vlachogiannakos
- Academic Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Marc C Burgmans
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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11
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Tan M, Zhang W, Zhou H, Liu Y, Lu T, Zhang Y, Li C, Yang Y, Wu Y, Hu H, Li Y, Yang F, Lin S. VariScreen secures the screening of high-risk varices in patients with hepatitis B virus-related cirrhosis beyond Baveno VI criteria. Front Physiol 2022; 13:1006657. [PMID: 36237519 PMCID: PMC9551454 DOI: 10.3389/fphys.2022.1006657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/09/2022] [Indexed: 12/07/2022] Open
Abstract
We aimed to validate the performance of the ratio of the platelet count (PLT) to liver stiffness measurement (LSM) in excluding high-risk varices (HRVs) in patients with hepatitis B virus (HBV)-related compensated cirrhosis beyond Baveno VI criteria. A total of 310 patients were assessed. The performances of the PLT:LSM ratio (PLER), PLER adjusted for the international normalized ratio, etiology, age, and sex (PLEASE), and the sequential algorithm for HRV screening (VariScreen) in excluding HRVs were evaluated and compared with those of expanded Baveno VI criteria (LSM <25 kPa and PLT >110×109/L, EB6C); PLT >150×109/L and model for end-stage liver disease score = 6 (P150M6 criterion); PLT >120×109/L and albumin >36 g/L (P120A36 criterion); and albumin-bilirubin (ALBI) grade and PLT score (ALBI-PLT score). Among the enrolled patients, 43 (13.9%) had HRVs. The area under the receiver operating characteristic curve of PLER for predicting HRVs (0.771, 95% confidence interval, 0.720–0.817) was significantly higher than that for PLT and LSM (p < 0.01). PLER was an independent risk factor for HRVs. VariScreen, PLEASE, and PLER could spare 20 (6.5%), 91 (29.4%), and 60 (19.4%) endoscopies, with 0, 3 (3.3%), and 1 (1.7%) HRVs missed, respectively. The EB6C and P120A36 criteria could spare 45 (14.5%) and 36 (11.6%) endoscopies, with 1 (2.2%) and 1 (2.8%) HRVs missed, respectively. The P150M6 criterion and ALBI-PLT score missed 6.8% and 10.3% of HRVs, respectively. We found that PLER performed better than other non-invasive tests. VariScreen secured the screening of HRVs in patients with HBV-related cirrhosis beyond Baveno VI criteria.
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Affiliation(s)
- Min Tan
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Infectious Diseases, Suining Central Hospital, Suining, China
| | - Wuxiang Zhang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- Department of Infectious Diseases, The Third Affiliated Hospital of Zunyi Medical University (The First People’s Hospital of Zunyi City), Zunyi, China
| | - Hong Zhou
- Department of Infectious Diseases, Suining Central Hospital, Suining, China
| | - Yujuan Liu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Tao Lu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yin Zhang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Chuan Li
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yanyan Yang
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yunchong Wu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Han Hu
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Ying Li
- Department of Infectious Diseases, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Fangwan Yang
- Department of Infectious Diseases, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Shide Lin
- Department of Infectious Diseases, Affiliated Hospital of Zunyi Medical University, Zunyi, China
- College of Laboratory Medicine, Zunyi Medical University, Zunyi, China
- *Correspondence: Shide Lin,
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